TLA offers many patient advantages

New Orleans - According to Alvaro E. Acosta, M.D., the growing use of tumescent local anesthesia (TLA) will not only attract more surgeons to its benefits, but will lead to a multitude of new applications.

Dr. Acosta, chief of the department of dermatology and oncology at the National Cancer Institute of Colombia, Bogota, discussed TLA and its benefits in his seminar, "Tumescent local anesthesia in reconstructive skin cancer surgery," during the recent 63^rd Annual Meeting of the American Academy of Dermatology, here.

What is it? "TLA is a regional anesthesia technique for the skin and subcutaneous tissue," Dr. Acosta says. "It is applied by directly infiltrating large volumes of a dilute local anesthetic. 'Tumescent' refers to the swelling of the anesthetized skin after infiltration of the TLA solution has taken place."

"Many older patients suffering from cutaneous malignancies also have other health problems, which makes them high-risk candidates for general anesthesia," Dr. Acosta says. "Also, major skin cancer surgery (MSCS) involving large tumors and/or complex reconstructive procedures has been limited by the restrictions of administering safe dosages of lidocaine. TLA has made it possible to increase the total dose of lidocaine five- to seven-fold without it resulting in toxic levels or negative side effects."

Dr. Acosta says the TLA's advantages were first recognized in cosmetic dermatologic surgery, and that TLA has since become standard procedure in such operations. Among other procedures, he says, TLA is now also used in:

"I've applied TLA during MSCS to more than 1,000 patients," Dr. Acosta says. "Each patient I operate on receives the same TLA solution, which consists of 100 ml of 0.9 percent sodium chloride, 10 ml of 1 percent lidocaine, plus epinephrine and 1 mEq sodium bicarbonate. The active substances of the TLA solution are added to the saline solution just before it's injected."

He says the total volume can vary between 100 to 200 ml, and that the amount of tumescent solution applied depends upon the area where the skin cancer is located, as well as upon the type of reconstruction that will be needed.

Pre-op "Before the anesthesia is administered, the surgeon should first design and then draw the flap upon the patient's skin," Dr. Acosta says. "Once that's done, about 1 ml of the TLA solution is injected intradermally with a 27-gauge needle. One to five seconds later, when the pain from the initial injection has subsided, the rest of the solution can be injected intradermally and subcutaneously with a 21-gauge needle on a 3-ml syringe. This injection continues until uniform tumescence of the lesion and perilesional area occurs."

Dr. Acosta says the surgery can be performed 10 minutes after completing injection of the TLA solution.

"In my experience, bleeding has not been a problem when operating with TLA," he says. "In a study I did, bleeding was mild in 79 percent of the patients, and in 25 percent of the total cases, it was not necessary to use electrocoagulation or any other kind of hemostasis. Among the few patients who suffered moderate bleeding during surgery, the cause was associated with hypertension and/or the taking of aspirin or a nonsteroidal anti-inflammatory drug.